Documentation Basics

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. This new second edition continues the path of teaching the student and clinician documentation from A to Z. It has been updated to reflect changes of the American Physical Therapy Association and the ever-evolving profession.

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Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.

Mia Erickson and Rebecca McKnight have updated this Second Edition to reflect changes of the American Physical Therapy Association and the ever-evolving profession.

Updated inside Documentation Basics: A Guide for the Physical Therapist Assistant, Second Edition:



The discussion on integrating disablement into documentation
The discussion on how a PTA can show medical necessity and need for skilled care
The discussion on using documentation to communicate with other providers
Writing the assessment and plan to coincide with the initial documentation
Sample notes completed on forms
More examples and practice, including physical agents, school-based services, paediatrics, traumatic brain injury, spinal cord injury, and interventions consistent with the Guide to Physical Therapist Practice
Medicare reimbursement in different settings
The importance of consistent, reliable, and valid measurements
How to improve communication and consistency between documentation by the PT & the PTA

The discussion on disablement has also been updated, shifting away from the Nagi Model toward the International Classification of Functioning, Disability, and Health (ICF). In addition, the PTA Normative Model has been integrated throughout to include more information on clinical decision making.

New inside Documentation Basics: A Guide for the Physical Therapist Assistant, Second Edition:



Navigating the PT plan of care…A step-by-step model for PTAs to use as they navigate the initial PT documentation and plan of care
How the PTA uses the PT goals from the initial examination and evaluation
Positive and negative aspects of using electronic documentation and a discussion on integrating SOAP notes and the problem-oriented medical record into electronic documentation
Sample notes and discussion of documentation in school-based settings, early intervention, skilled nursing settings, in-patient rehabilitation, and direct access
Medicare Parts C and D
Cash-based services and pro bono services

Instructors in educational settings can visit www.efacultylounge.com for additional material to be used for teaching in the classroom.

Documentation Basics: A Guide for the Physical Therapist Assistant, Second Edition is the perfect guide for all physical therapist assistant students and clinicians who want to update and refine their knowledge and skills in documentation.